Provider Demographics
NPI:1710390562
Name:WILD, MICHAEL JOHN (MS, ATC, PES)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:WILD
Suffix:
Gender:M
Credentials:MS, ATC, PES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5963 ROUTE 98
Mailing Address - Street 2:PO BOX 7
Mailing Address - City:GREAT VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14741-0007
Mailing Address - Country:US
Mailing Address - Phone:716-969-7581
Mailing Address - Fax:716-566-7858
Practice Address - Street 1:4380 MAIN ST
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14226-3544
Practice Address - Country:US
Practice Address - Phone:716-839-8581
Practice Address - Fax:716-566-7858
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY79522612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer